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THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW THIS CAREFULLY.

Our Privacy Commitment

Thank you for giving us the opportunity to serve you. In the normal course of business – providing medical care to you - Rice Clinic creates records about you and the treatment and services we provide to you. The information we collect is called Protected Health Information (PHI). We take our obligation to keep your PHI secure and confidential very seriously. We are required by federal and state law to protect the privacy of your PHI in your healthcare records and any other identifiable patient health information used or disclosed by us in any form and provide you with this Notice about how we safeguard and use it. We are also required by law to notify you following a breach of your unsecured PHI. When our office, its employees, Business Associates and other involved parties use or disclose your PHI, we are bound by the terms of this Notice that is currently in effect. This Notice applies to all electronic or paper records we create, obtain and/or maintain that contain your PHI, including clinical notes, lab results, x-rays and medication history. After reading this Notice, we will need your signature on a written, dated Consent or Acknowledgement Form before we will use or disclose your PHI for certain purposes. You may request and receive a copy of this Notice. You may take back or revoke your consent or authorization at any time (unless we have already acted based on it) by submitting to us in writing a revocation. Your revocation will take effect when we receive it. It will not affect what we have already used or disclosed in our reliance on your consent. If you do not sign our Authorization/Acknowledgement Form or if you revoke it in the future, your PHI may be used or disclosed as permitted or required by law.

This Notice of Privacy Practices is NOT an authorization.

How We Protect Your Privacy

We restrict access to your PHI to authorized workforce members (employees, volunteers, trainees and business associates) who need that information for your treatment, for payment purposes, and/or for health care operations. We maintain technical, physical and administrative safeguards to ensure the privacy of your PHI. To protect your privacy, only authorized and trained workforce members are given access to our paper and electronic records and to non-public areas where this information is stored. Our workforce members are trained on HIPAA and the privacy and data protection required for PHI as well as maintaining technical, physical and administrative safeguards in place to maintain the privacy and security of your PHI. Should you have any questions, please ask to speak to our business manager, Paula Faulkner.

How We Use and Disclose Your PHI

Uses/disclosures of your PHI without your authorization

Treatment:

To coordinate your healthcare and services with a different healthcare facility or professional.

To share with nurses, doctors, pharmacies, health educators and other health care professionals so they can determine a plan of care.

To consult with your family or others so they may assist you with home care.

To verify insurance coverage and/or receive authorization for a procedure.

To submit claims to your health plan or third party for payment.

To bill or collect payment from you.

You may restrict disclosure to your insurance carrier for services if you pay “out of pocket” in full for the services.

To coordinate benefits with other coverage you may have.

Healthcare Operations

To provide customer service such as appointment reminders, calling you by name in the waiting room, placing your name on a sign-in sheet, recommending or informing you of health-related products and complementary or alternative treatments that may interest you. If you prefer we not contact you with appointment reminders or information about treatment alternatives or health-related products and services, you may notify us of this in writing and we will not use or disclose your PHI for these purposes.

To support and/or improve the programs or services we offer you.

Disclosure to Other Individuals in Your Health Care

To family members but only if you are present and verbally give permission.

If you are in an emergency situation and are not present or are incapacitated, we will use our professional judgment and the surrounding circumstances to decide whether disclosing your PHI to others is in your best interest. If we do disclose your PHI in a situation where you are unavailable, we will only disclose information that is directly relevant to your treatment or for payment related to your treatment. We may also disclose your PHI in order to notify or assist in notifying such persons of your locations, your general medical condition, or your death.

We may disclose your child’s PHI to your child’s other parent.

If you do not want us to disclose your PHI or your child’s PHI to others, please let us know

You may name another individual to act as your personal representative. Your representative will be allowed access to your PHI, to communicate with the health care professionals and facilities providing your care and to exercise all other HIPAA rights on your behalf. Depending on the authority you grant your representative, this person may also have authority to make health care decisions for you.

Special situations when your PHI will be disclosed/used without your authorization:

As Required by Law E.g., child and elder abuse, domestic violence

To Avert a Serious Threat to Health or Safety of the Public or another Person.

Business Associates

We may disclose PHI to our business associates that perform functions on our behalf or provide us with services if the information is necessary for such functions or services.

Organ and Tissue Donation

If you are an organ donor, we may use or disclose PHI to organizations that handle organ procurement

Military and Veterans

If you are a member of the armed forces, we may disclose PHI as required by military command authorities.

If you are involved in a lawsuit or dispute, we may disclose PHI in response to a court order or administrative order, subpoena, discovery request or other lawful process. We will make every effort to tell you of the request.

Law Enforcement

In response to a court order, subpoena, warrant, summons or similar process;

About the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person’s agreement;

About a death we believe may be in the result of criminal conduct;

About criminal conduct on our premises; and

In an emergency to report a crime, the location of the crime or victims, or the identity, description or location of the person who committed the crime.

Correctional Institution

If you are or become an inmate of a correctional institution, we may disclose PHI to the institution or its agents when necessary for your health or the health and safety of others.

National Security and Intelligence Activities

We may release PHI about you to authorized federal officials for intelligence, counterintelligence and other national security activities authorized by law.

Coroners, Medical Examiners and Funeral Directors

This may be necessary, for example, to identify a deceased person or determine the cause of death.

We also may release PHI to funeral directors as necessary for their duties.

For Research

Those projects approved by a review board to ensure confidentiality; you will be asked to sign an authorization.

Uses of PHI that require your authorization

Other uses and disclosures as set forth below will be made only with your consent, authorization or opportunity to object unless required by law. The following categories of information that are marked with an * are considered sensitive and require enhanced privacy protection:

Psychotherapy notes *

Alcohol and drug abuse prevention, treatment and referral notes *

HIV/AIDS testing, diagnosis or treatment *

Any PHI that contains genetic information that will be used for underwriting purposes *

PHI that is used for marketing purposes

Disclosures that constitute a sale of your PHI

YOUR INDIVIDUAL RIGHTS

You have the following rights regarding the PHI that we create, obtain, and/or maintain for you.

Obtain a paper copy of the Notice upon request. At your request, we will provide you with a copy of this Notice. We are required to follow the terms of this Notice currently in effect but reserve the right to change the terms of our Notice at any time.

To inspect and copy your PHI. You may request in writing to review or receive a copy of your PHI that is included in certain paper or electronic records we maintain. Under limited circumstances, we may deny you access to a portion of your records. All original records will remain on the premises and will only be available for inspection during regular business hours. You will have the right to request a copy in electronic format if your health record is maintained electronically. If your PHI is maintained in electronic format but is not readily producible in such format, we will produce it in a readable electronic format upon which we agree. We have the right to charge a reasonable fee for paper or electronic copies.

Right to request restrictions. You may ask to restrict the way we use and disclose your PHI for treatment, payment, and health care operations as explained in this Notice. We are not required to agree to the restrictions. If we agree to the restrictions, we will follow them except in an emergency where we will not have time to check for limitations, in which case we will ask the receiving person not to further use or disclose your PHI. We will honor your request to restrict information to your health plan or insurer about a visit, service or prescription for which you have paid in full provided that disclosure is not otherwise required by law. You may exercise this right at the time of service. If you do so, no claim or communication with your health plan or insurer will occur.

Right to receive notice of a breach. You have the right to be notified upon a breach of any of your unsecured PHI.

Right to amend your records. You may ask us to correct or amend your PHI contained in our electronic or paper records if you believe it is inaccurate or something is missing. We will act on your request within 30 days from receipt of a written request. If we determine the information is inaccurate, we will notify you in writing and make the changes by noting (not deleting) what is incorrect or incomplete and adding the changed language. We may deny your request under certain circumstances. If we deny your request, we will notify you in writing and you may file a complaint with us if you disagree. If you are not satisfied with our decision, you may complain to the U.S. Department of Health and Human Services. If a different health care facility or professional created the information that you want changed, you should ask them to amend the information.

Right to receive confidential communications. You may ask us in writing to communicate with you in a different way or at a different place. We will accommodate all reasonable requests whenever feasible.

Right to receive an accounting of disclosures. Upon your written request, we will provide a list of the disclosures we have made of your PHI for a specified period of time. However, the list will exclude:

Disclosures you have authorized.

Disclosures made earlier than six (6) years before the date of your request or three (3) years in the case of disclosures made from an electronic health record.

Disclosures made for treatment, payment and health care operations purposes.

Disclosures as excepted by law.

Disclosures to you or to your personal representative.

Disclosures incidental to a use or disclosure that is otherwise permitted or required by law.

Your request must state in what form you want the list (paper or electronically) and the time period you want us to cover. If you request an accounting more than once during any 12 month period, we will charge you a reasonable fee for each accounting report after the first one.

ACTIONS YOU MAY TAKE

Contact us. If you have any questions about your privacy rights, believe that we may have violated your privacy rights or disagree with a decision that we made about access to your PHI, you may contact us at the following address or telephone number. Paula Faulkner - Rice Clinic, P.A. / 1301 Wilson Road, Little Rock, AR 72205 / (501) 225-0576 / paula@rice-clinic.com

Contact a government agency. If you believe we may have violated your privacy rights, you may also file a written complaint with the Secretary of the U.S. Department of Health and Human Services (HHS).Your complaint can be sent by email, fax or mail to the HHS’ Office for Civil Rights (OCR). You will not be retaliated against for filing a complaint. For more information, go to the OCR website www.hhs.gov/ocr/privacy/hipaa/complaints. Mailed complaints may be directed to: Office of Civil Rights, Region IV / U.S. Department of Health and Human Services / 1301 Young Street, Suite 1169, Dallas, Texas 75202 / Fax: 1- 214-767-0432

NOTICE AVAILABILITY AND DURATION

Notice Availability. A copy of this Notice is available from our office(s) and is posted in prominent locations in our office at all times.

Right to change terms of this Notice. We may change the terms of this Notice at any time, and we may, at our discretion, make the new terms effective for all of your PHI in our possession, including any PHI we created or received before we issued the new Notice.

If we change this Notice, we will give you the new Notice when you receive treatment. In addition, we will post any new Notice in a prominent location in our office(s).

Effective Date. These privacy practices are in effect as of April 14, 2003 and will remain in effect until we revise them as permitted or required by law.

About us

The Rice Clinic is a Christian Based mental health clinic that helps individuals and families cope with difficulties and challenges that are encountered within a lifetime.

Our team of therapists, psychologists, a psychiatric nurse practitioner, and psychiatrists integrate Biblical principles with psychological and medical resources to provide the very finest in health care.